*** Ballot initiatives were passed in 2018 in Utah, Nebraska, and Idaho, calling for full Medicaid expansion. Since then, Utah has partially expanded Medicaid, Idaho plans to expand coverage as of January 2020, and Nebraska plans to expand coverage as of late 2020.***
Medicaid expansion states: Key takeaways
- 33 states and DC have accepted federal funding to expand Medicaid under the ACA, and at least three more are in the process of expanding in 2019/2020.
- Maine approved a ballot initiative in 2017 to expand Medicaid, which took effect in 2019. Utah, Idaho, and Nebraska approved expansion initiatives on their 2018 ballots.
- In 2018, Virginia lawmakers approved Medicaid expansion, which took effect in January 2019.
- Eight states have received federal approval for Medicaid work requirements. Several others have pending waivers or are considering submitting waivers.
- Some states are attempting to change Medicaid by implementing lifetime caps on coverage, or by adjusting eligibility requirements.
- A handful of states have been exploring Medicaid buy-in programs.
- Seventeen states have yet to take the ACA’s Medicaid expansion. It was 19 as of mid-2018, but Maine and Virginia expanded coverage as of 2019.
- Michigan, New Hampshire, Indiana, Pennsylvania, Alaska, Montana, and Louisiana expanded their Medicaid programs after January 2014, but before the end of 2016. Virginia expanded Medicaid as of January 2019, and Maine expanded coverage as of February 2019. Utah, Nebraska, and Idaho are also expected to expand Medicaid in 2019, although coverage might not be available until 2020 in some cases.
- The 14 states that haven’t expanded coverage (not counting Utah, Idaho, and Nebraska) are missing out on $305 billion in federal funding if they continue to reject expansion.
- Public support for Medicaid expansion is strong, with 56 percent of the public in favor of expansion even in deep-red Wyoming.
When the Affordable Care Act was enacted in 2010, Medicaid expansion was a cornerstone of lawmakers’ efforts to expand realistic access to healthcare to as many people as possible. The idea was that everyone with household incomes up to 133 percent of poverty (138 percent with the 5 percent income disregard) would be able to enroll in Medicaid.
Since 2010, the number of states that have accepted ACA’s Medicaid expansion has steadily grown – from just a handful by 2012 to 33 states and DC as of mid-2019. Utah, Idaho, and Nebraska all passed ballot initiatives to expand Medicaid, with coverage expansions going into effect in 2019 and 2020.
At the same time, there are a host of other Medicaid-related developments in the works across the country – both in expansion and non-expansion states – that promise to dramatically affect eligibility for and access to Medicaid benefits. Some states are moving toward changes that would put increased limits on Medicaid eligibility – such as work requirements and lifetime caps – while other states are considering legislation that would give currently ineligible residents a chance to buy-in.
Suffice it to say, there’s plenty of activity to monitor at the state level.
States to watch for Medicaid changes
Several states are considering various changes to their Medicaid systems in 2019. In some cases, lawmakers are considering expansion or seeking a federal waiver to change the way Medicaid eligibility is handled. In other states, lawmakers and state officials are working to address new voter-approved ballot initiatives that call for Medicaid expansion:
Medicaid expansion with a ballot initiative
Maine voters approved a ballot initiative in the 2017 election, calling for Medicaid expansion in Maine by July 2018. Former Governor Paul LePage refused to move forward with implementation, and a legal battle ensued throughout 2018. But Governor Janet Mills took office in January 2019, and made an expeditious Medicaid expansion one of her top priorities. By mid-February, more than 6,000 people were enrolled in Maine’s expanded Medicaid, and the enrollment process was ongoing.
Medicaid expansion was on the ballots in three other states in 2018, and Montana voters were given the chance to decide whether to continue Medicaid expansion in the state and fund it with an additional tax on tobacco products:
- Utah: Medicaid expansion passed, by a vote of 54 to 46. Under the terms of the ballot initiative, the state was to submit a Medicaid expansion plan to the federal government by April 1, 2019. Instead, Utah’s GOP-controlled legislature passed SB96, and Gov. Herbert signed it into law less than three weeks after it was first introduced. The legislation replaces Utah’s voter-approved ballot initiative with a stripped-down version of Medicaid expansion: SB96 called for the state to seek federal approval to expand Medicaid only to 100 percent of the poverty level, instead of 138 percent (as called for in the ACA and the state’s ballot initiative), and also imposes a work requirement. The state implemented expansion for people earning up to the poverty level as of April 2019, but CMS subsequently rejected the state’s request for full Medicaid expansion funding for that population. The state’s fallback option is full expansion with a work requirement, which will require another round of negotiations with the federal government.
- Idaho: Medicaid expansion passed, by a vote of 60 to 40, and expansion will take effect in Idaho as of January 2020. But Idaho enacted legislation in 2019 that imposes various modifications, including a work requirement and a “coverage choice” option that will allow some residents to choose between Medicaid and subsidized plans in the exchange. The state is working to gain federal approval for these provisions.
- Nebraska: Medicaid expansion passed, by a vote of 53 to 47. Proponents of Medicaid expansion in Nebraska were hoping that enrollment would begin by the fall of 2019, with coverage effective January 1, 2020, but the state is taking a much slower approach, with expansion slated to begin in late 2020 instead.
- Montana: Medicaid had already expanded in Montana, but that was scheduled to end in June 2019 unless it was reauthorized. The ballot initiative was to generate funding, via a tobacco tax, to help pay for the state’s share of the cost of ongoing expansion, and to provide for ongoing Medicaid expansion that doesn’t have to be reauthorized. The measure failed, however, by a vote of 53 to 47. Instead, lawmakers in Montana passed legislation to extend Medicaid expansion for another six years, but with a provision requiring the state to seek federal approval for a Medicaid work requirement.
Legislation to expand Medicaid
Lawmakers in the states that haven’t expanded Medicaid have continued to introduce legislation each year in an effort to expand coverage. In 2018, Virginia lawmakers passed a budget that includes Medicaid expansion, with coverage effective January 2019 (enrollment began in November 2018). Medicaid expansion in Virginia was expected to make coverage newly-available to 400,000 residents. Lawmakers plan to seek federal approval for a Medicaid work requirement, but it could be two years before that come to fruition — assuming work requirements withstand the judicial rulings against them.
Medicaid work requirements
Requiring people to be working (or volunteering, in school, in job training, etc.) for at least a certain number of hours per week is an idea that tends to be popular with Republican lawmakers. Most people who receive Medicaid benefits are either already working or would be exempt from work requirements (due to being disabled, taking care of a minor child, pregnant, etc.), but the myth of the “welfare queen” (or king) persists, and Medicaid work requirements are seen by some as a solution to a perceived problem.
The federal Centers for Medicare and Medicaid Services (CMS) has to approve a Medicaid work requirement before a state can implement it. The Obama Administration did not allow any work requirements for Medicaid, but the Trump Administration has been much more open to the idea.
As of mid-2019, eight states had received federal approval for work requirements, and several others have pending waivers or are expected to submit waivers in the near future. However, a federal judge has overturned Medicaid work requirements in Arkansas, Kentucky, and New Hampshire, citing the fact that numerous people are expected to lose coverage under the terms of the work requirements (as was the case in Arkansas while their work requirement was in effect in 2018), and government had done nothing to ameliorate that problem.
The Trump administration and the affected states are appealing the court ruling, but the issue is in legal limbo for the time being, and work requirements are not currently in effect in any states (Arkansas paused its program in 2019, New Hampshire had already delayed its program before it was overturned, and the judge’s ruling that overturned Kentucky’s work requirement came just days before it was to take effect). Several states have approved work requirements that are slated to take effect in 2020.
You can click on the link for each state to learn more about the approved or proposed work requirements.
Work requirements for states that have expanded Medicaid:
- Arkansas (CURRENTLY PAUSED AFTER JUDGE OVERTURNED THE WORK REQUIREMENT) approved, effective June 2018 for people age 30-49; people age 19-29 will have to comply as of 2019. — 80 hours per month
- Indiana (approved, phased in, starting in 2019) — 5 hours per week initially, increasing to 20 hours per week
- New Hampshire (CURRENTLY PAUSED AFTER JUDGE OVERTURNED THE WORK REQUIREMENT) approved, initially scheduled to take effect in April 2019, but delayed until September 2019 — 100 hours per month
- Kentucky (CURRENTLY PAUSED AFTER JUDGE OVERTURNED THE WORK REQUIREMENT) approved, was to be effective July 2018, but a federal judge halted the implementation of the work requirement in late June; CMS reopened the comment period and ultimately reapproved the work requirement, with no substantial changes, with an April 2019 effective date. — 80 hours per month
- Michigan (approved, effective January 2020, but might be changed or disregarded under Governor-elect Gretchen Whitmer) — 80 hours per month (Michigan legislation initially called for 29 hours per week of work/community engagement, but it was revised to 80 hours per month before the final bill passed). In the 2018 election, while the work requirement waiver was pending federal approval, Michigan voters elected Democrat Gretchen Whitmer to be the state’s next governor. The details of the work requirement are in state law, so it’s unclear how much leeway Whitmer will have to avert or modify the proposed work requirement. But her administration is likely to push back on at least some aspects of it.
- Arizona (approved, effective January 2020) — 80 hours per month for people age 19 to 49.
- Ohio (approved; Ohio plans to implement the work requirement as of January 2021) — 20 hours per week
- Virginia enacted a budget that calls for Medicaid expansion starting in January 2019, but also directs the state to seek federal permission for a work requirement. The work requirement would phase in, starting with 20 hours per month after a person has been enrolled for three months, and ramping up to 80 hours per month by the time the person has been enrolled for a year. The work requirement is also likely to be delayed up to two years after expansion takes effect.
- Idaho — State plans to submit a proposal to CMS in August 2019, seeking approval for a work requirement. Medicaid expansion will take effect in Idaho in January 2020.
- Montana — Montana is accepting public comments (through August 23, 2019) on a Medicaid work requirement waiver proposal that the state plans to submit to the federal government.
Lawmakers in Louisiana considered several work requirement bills in 2018, but none were enacted. Lawmakers in Pennsylvania passed Medicaid work requirement legislation in 2017 and again in 2018, but Governor Tom Wolf vetoed both bills.
Work requirements for states that have not expanded Medicaid:
Several states that have not expanded Medicaid are seeking federal permission to impose Medicaid work requirements, despite the fact that their Medicaid populations are comprised almost entirely of those who are disabled, elderly, or pregnant, as well as children.
The Trump Administration has begun granting work requirements in some of these states, although CMS Administrator, Seema Verma clarified in May 2018 that these states will have to clearly demonstrate how they plan to avoid situations in which people lose access to Medicaid as a result of the work requirement, and yet also do not have access to premium subsidies in the exchange. Thus far, two non-expansion states have been granted federal approval to implement Medicaid work requirements for their existing Medicaid populations:
- Wisconsin (approved; fulfilling the work requirement would be necessary to avoid the proposed 48-month cap on Medicaid benefits) — 80 hours per month. A week after CMS approved Wisconsin’s waiver, voters elected Democrat Tony Evers to be the state’s next governor, replacing Republican Scott Walker. Evers is opposed to the work requirement, but it’s unclear how much latitude his administration will have to adjust the waiver that CMS has approved.
- Maine (approved) — 20 hours per week. The work requirement can take effect as of July 2019 or later, under the terms of the federal approval that was granted in December 2018. Medicaid expansion has been approved by voters in Maine, but not yet enacted. The latest court ruling calls for expansion to be implemented by February 2019.
And the following non-expansion states are also seeking federal permission to impose a Medicaid work requirement:
- Mississippi (pending CMS approval) — 20 hours per week
- South Dakota (pending CMS approval) — 80 hours per month
- North Carolina (pending CMS approval, but lawmakers would have to first approve the Carolina Cares legislation, which calls for expanded Medicaid with a work requirement; North Carolina has not proposed a work requirement for the currently-eligible Medicaid population)
- Utah (pending CMS approval for Primary Care Network population; proposed for modified expansion) 20 or 30 hours per week, depending on circumstances (aligned with TANF rules). As described above, Utah has also enacted legislation in 2019 calling for limited Medicaid expansion with a work requirement, all of which will need federal approval in order to be implemented.
- Alabama (pending CMS approval) — 35 hours per week.
- Tennessee (pending CMS approval — 20 hours per week.
- Oklahoma (pending CMS approval — 80 hours per month.
Kansas had also requested CMS approval for a work requirement of 20 or 30 hours per week, depending on circumstances. But that provision was later removed from the state’s Medicaid renewal proposal, and the waiver approval that was granted by CMS in December 2018 did not include a work requirement.
Other Medicaid proposals to watch
Several states have sought CMS approval to implement lifetime caps for Medicaid coverage, including Arizona, Kansas, Maine, Utah, and Wisconsin. But thus far, CMS has not approved this provision for any states. Arizona’s work requirement approval noted that CMS was rejecting the state’s proposal to cap eligibility at five years for people who were subject to, but not in compliance with, the work requirement.
The Trump Administration also rejected Arkansas’ proposal to cap Medicaid eligibility at 100 percent of the poverty level, instead of 138 percent. Massachusetts has a similar request pending CMS approval, and Utah enacted legislation in 2019 (and in 2018) directing the state to seek approval to expand Medicaid only to those earning up to the poverty level.
And no states have received approval for an asset test for Medicaid, although some, including Maine, are seeking such approval.
Several states have received approval, however, to impose premiums on certain Medicaid populations, restrict retroactive eligibility, and require more eligibility redeterminations.
New Hampshire enacted legislation in 2018 that directed the state to abandon the private approach to Medicaid expansion that was being used in the state at the time (buying policies in the exchange for people eligible for expanded Medicaid) and switch to a Medicaid managed care program instead. The state submitted a waiver amendment proposal to CMS in August 2018, seeking permission to implement the changes, and is planning to transition to Medicaid managed care by mid-2019 (although the July 1, 2019 target date might not be met).
Some states have also considered the possibility of seeking approval for a Medicaid buy-in program, under which people who aren’t eligible for Medicaid would be allowed to purchase Medicaid coverage. Nevada lawmakers passed legislation to do so in 2017, but the governor vetoed it. Lawmakers in Colorado, Maryland, and New Mexico considered legislation in 2018 that would direct the state to conduct a study on the feasibility and cost of a Medicaid buy-in program (ie, allowing people who aren’t eligible for Medicaid to purchase Medicaid coverage instead of private market coverage). Colorado lawmakers ultimately did not pass the bill, and neither did Maryland lawmakers. But New Mexico enacted legislation in early 2018 calling for a study on the costs and ramifications of a Medicaid buy-in program, and New Mexico lawmakers are considering SB405, which would create a Medicaid buy-in program, during the 2019 legislative session.
Minnesota lawmakers considered, but did not pass, a bill in 2017 that would have allowed people to buy into MinnesotaCare, the state’s Basic Health Program (similar to Medicaid, but for people with slightly higher income). This issue was revisited in 2018 and DFLers still support it in 2019, but it hasn’t gone anywhere yet.
Thus far, Medicaid buy-in has not gained much traction. But Democrats have been warming to the idea of a public option or single payer system, and Medicaid buy-in would certainly be a step in that direction.
History of Medicaid expansion
As noted at the start of this summary, Medicaid was a cornerstone of ACA lawmakers’ efforts to expand access to healthcare. The idea was that everyone with household incomes up to 133 percent of the federal poverty level (FPL) would be able to enroll in Medicaid.
People above that threshold – but whose incomes didn’t exceed 400 percent of FPL – would be eligible for premium tax credits in the exchanges to make their coverage affordable. And although there are some exceptions, most people in the individual health insurance market with incomes above 400 percent of poverty are able to afford insurance even though they don’t qualify for subsidies.
(Regardless of income, people who get their insurance from an employer receive subsidies in the form of the employer’s contribution to their premiums – and their premiums are pre-tax).
Because Medicaid expansion was expected to be a given in every state, the law was written so that premium subsidies in the exchange are not available to people with incomes below the poverty level. They were supposed to have access to Medicaid instead.
17 states still say ‘No’ to Medicaid expansion (but Utah, Idaho, and Nebraska are working on at least modified expansion in 2019/2020)
Unfortunately for millions of uninsured Americans, in 2012 the Supreme Court ruled that states could not be penalized for opting out of Medicaid expansion. And 17 states have not yet expanded their programs. (Until late 2015, there were still 22 states that had not expanded Medicaid, but Montana began enrolling people in their newly expanded Medicaid program in November 2015, for coverage effective January 2016, Alaska‘s Medicaid expansion took effect in September 2015, Louisiana‘s Medicaid expansion took effect in July 2016, and Virginia began enrolling people in expanded Medicaid as of November 2018, for coverage effective January 2019. Maine expanded Medicaid as soon as Governor Mills took office in early 2019. Utah, Idaho, and Nebraska are expected to expand Medicaid in 2019 (but with coverage effective dates likely to be in 2020 and modifications to the regular Medicaid expansion called for in the ACA), under the terms of the ballot initiatives that passed in each state in November 2018.
As a result of the failure to expand coverage in the 17 states, the Kaiser Family Foundation estimates there are 2.1 million people in the coverage gap across 16 of those states (although Wisconsin has not expanded Medicaid under the ACA, BadgerCare Medicaid is available for residents with incomes up to the poverty level, so there is no coverage gap in Wisconsin). The Kaiser Family Foundation analysis continues to include Utah, Nebraska, and Idaho among the states where coverage has not been expanded, but their coverage gaps will hopefully be closed by 2020, and their combined total number of residents in the coverage gap is only 84,000 people.
Being in the coverage gap means you have no realistic access to health insurance. These are people with incomes below the poverty level, so they are not eligible for subsidies in the exchange. But they are also not eligible for their state’s Medicaid program.
In many of the states that have not expanded Medicaid, low-income adults without dependent children are ineligible for Medicaid, regardless of how little they earn. For those who do have dependent children, the income limit for eligibility can be very low: In Alabama, parents with dependent children are only eligible for Medicaid if their income doesn’t exceed 13 percent of the poverty level. For a family of three, that’s only $231 per month (and yet, Alabama wants to impose a work requirement on those parents who are currently eligible for coverage).
More states easing into expansion
The 2018 election was pivotal for Medicaid, with three states passing ballot initiatives to expand Medicaid, and Kansas, Wisconsin, and Maine electing governors who are supportive of Medicaid expansion (Maine voters had already approved Medicaid expansion in the 2017 election, but it wasn’t implemented until early 2019, when the state’s new governor took office).
The first six states to implement Medicaid did so in 1966, although several states waited a full four years to do so. And Alaska and Arizona didn’t enact Medicaid until 1972 and 1982, respectively. Eventually, Medicaid was available in every state, but it certainly didn’t happen everywhere in the first year.
There’s big money involved in the Medicaid expansion decision for states. Under ACA rules, the federal government pays the vast majority of the cost of covering people who are newly eligible for Medicaid. Through the end of 2016, the federal government fully funded Medicaid expansion. The states started to pay a small fraction of the cost starting in 2017, eventually paying 10 percent by 2020. From there, the 90/10 split is permanent; the federal government will always pay 90 percent of the cost of covering the newly eligible population, assuming the ACA remains in place.
The cost of NOT expanding Medicaid eligibility
Because the federal government funds nearly all of the cost of Medicaid expansion, the 14 states that haven’t yet taken action to expand Medicaid are missing out on more than $305 billion in federal funding between 2013 and 2022, if they continue to reject Medicaid expansion.
[Indiana, Pennsylvania, Alaska, Montana, Louisiana, Virginia, and Maine have expanded their Medicaid programs since that report was produced in 2014, so they are no longer missing out on federal Medicaid expansion funding. Utah, Nebraska, and Idaho are expected to expand Medicaid in 2019 or 2020, and will begin receiving federal Medicaid expansion funding at that point, so they’re also not included in the $305 billion total. It’s noteworthy, however, that if Utah pushes forward with its bid to cap Medicaid expansion at 100 percent of the poverty level, they may only be able to get the state’s normal federal match rate of about 70 percent, instead of the 90 percent match rate that goes along with Medicaid expansion; in other words, they would be leaving a substantial amount of money on the table, and covering fewer people.]
Just five states – Florida, Texas, North Carolina, Georgia, and Tennessee – would have received nearly 60 percent of that funding (a total of $227.5 billion) if they had expanded Medicaid to cover their poorest residents starting in 2013. The good news is that although the federal government is no longer funding the full cost to expand Medicaid, they’ll always pay at least 90 percent of the cost, making Medicaid expansion a good deal for states regardless of when they implement it (in other words, for every dollar a state spends to cover its Medicaid expansion population, the federal government will kick in $9).
For residents of states that haven’t expanded Medicaid, their federal tax dollars are being used to pay for Medicaid expansion in other states, while none of the Medicaid expansion funds are coming back to their own states. From 2013 to 2022, $152 billion in federal taxes will be collected from residents in states not expanding Medicaid, and will be used to fund Medicaid expansion in other states.
Hospitals in states that don’t expand Medicaid are suffering too. Hospitals that treat large numbers of uninsured patients rely on federal funding from Disproportionate Share Hospital (DSH) payments to help cover the cost of the uncompensated care they provide. But DSH payments are being phased out by 2020, because Medicaid expansion was expected to sharply reduce the amount of uncompensated care hospitals must provide. Hospitals in states that have rejected Medicaid expansion will continue to provide a significant amount of uncompensated care, but their funding will be stretched even thinner than it already is.
The human toll of the Medicaid coverage gap
Of course, there’s more to Medicaid expansion than just money. Harold Pollack very clearly explains the human toll of the Medicaid coverage gap: Based on the 3,846,000 people who were expected to be in the coverage gap in January 2015, we can expect 4,633 of them to die in any given year because they don’t have health insurance. (Pollack’s number is higher, because his article was written in May 2014, before New Hampshire and Pennsylvania agreed to expand coverage; Indiana and Alaska also expanded coverage in 2015, and Montana‘s enrollment in Medicaid expansion began in November 2015, for coverage effective January 2016; Louisiana‘s Medicaid expansion took effect in 2016, Virginia‘s in January 2019, and Maine‘s in February 2019. There has been a slow but steady increase in the number of states that have expanded Medicaid).
There has been a slow push towards Medicaid expansion based on those financial and moral arguments, even in some of the reddest states. And the Supreme Court’s June 2015 ruling in King v. Burwell — which upheld the legality of premium subsidies in states that use the federally run health insurance exchange (Healthcare.gov) — gave new life to Medicaid expansion discussions in states that wanted to utilize Medicaid funds to purchase private health insurance for low-income residents (if the Court had struck down subsidies in states that haven’t created their own exchanges, the private insurance market would likely have destabilized and premiums would have skyrocketed).
Public support for Medicaid expansion
Public support for Medicaid expansion is relatively strong, even in Conservative-leaning states: In Wyoming (considered the most Conservative state), 56 percent of the public are in favor of Medicaid expansion. But the Republican-led legislature in Wyoming has consistently rejected Medicaid expansion, despite Republican former Governor Matt Mead’s support for expansion.
In Utah, 88 percent of the state’s residents supported Governor Herbert’s 2014 proposal for Medicaid expansion over the status quo, and public support for providing coverage for people in the Medicaid coverage gap has continued to be strong in Utah. Voters in the state approved a ballot initiative in the 2018 election to expand Medicaid, bypassing the legislature and governor altogether (although lawmakers and the governor acted swiftly in 2019 to pass new legislation that sharply limits the extent of the voter-approved Medicaid expansion ballot initiative in Utah). The same thing happened in Nebraska and Idaho in the 2018 election.
In Texas – home to more than a quarter of those in the coverage gap nationwide – a board of 15 medical professionals appointed by then-Governor Rick Perry recommended in November 2014 that the state accept federal funding to expand Medicaid, noting that the current uninsured rate in Texas is “unacceptable.” (U.S. census data indicated that 16.6 percent of Texas residents were uninsured in 2016 – the highest rate in the country.) But no real progress towards Medicaid expansion has been made since then.
There are several other states where the legislature or the governor – or both – are generally opposed to the ACA, but where Medicaid expansion has been actively considered, either by the governor or legislature or in negotiations with the federal government. These include Kansas, North Carolina, Tennessee, and Missouri, but thus far, none of those states have enacted legislation to expand Medicaid. Kansas lawmakers passed a Medicaid expansion bill in 2017, although then-Governor Sam Brownback vetoed it. But Kansas has elected a Democrat, Laura Kelly, to serve as the state’s next governor. If another Medicaid expansion bill passes in Kansas during her tenure, she can be expected to sign it into law.
Our Medicaid section provides updated state-by-state information on the current status of Medicaid expansion, along with general information about each state’s program. If you’re curious about what’s going on in your state, check it out.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.